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Child Study Action Plan Page 2
Child Study Action Plan (Tiers 2 and 3)
Student Name
Student ID
Grade
DOB
School
Date
Teacher
______ initial meeting
_______ review meeting
______ review meeting
_______ review meeting
______ review meeting
_______ review meeting
Committee Action: Please date each action.
____________ Continue in general education with implementation of Child Study Action Plan and schedule the child study committee
meeting review no later than ____________________________.
____________ Terminate Child Study Action Plan and continue in general education with Tier 1 modifications.
____________ Refer student for consideration for eligibility for special education services by requesting formal assessment. Request
parent/guardian to sign Form SE-2.
Committee Members Present
Printed Name
Signature
Title
Date (s)
Areas of Concern:
Achievement Data (compare to expected performance and
benchmarks):
Additional Information:
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